Healthcare Provider Details

I. General information

NPI: 1114851615
Provider Name (Legal Business Name): SCOTT CLIFFORD THURSTON ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 WASHINGTON ST
TOLEDO OH
43604-1046
US

IV. Provider business mailing address

2301 LAKELAND HILLS BLVD
LAKELAND FL
33805-2909
US

V. Phone/Fax

Practice location:
  • Phone: 970-389-6509
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL3499
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: